Please answer all of the following questions to determine if an authorization is needed:
Types of Services
Yes
No
Are services being provided by an out-of-network Provider?
Is the member being admitted to an inpatient facility?
Is the member receiving oral surgery services?
Is the member receiving plastic and reconstructive surgeon services?
Is the member receiving venous surgical procedures/services?
To determine if an authorization is needed enter CPT code below.
CPT code: 1:
2:
3:
4:
To submit a prior authorization
Login Here.
or use the
Texas Standard Prior Authorization Form for Health Care Services